Problems in the care of heart surgery patients at Waikato Hospital stretch back years, a Herald investigation has found. Nicholas Jones talks to a widow who says the DHB didn't learn from her husband's death.
Elizabeth Baker fell asleep relieved her husband's heart bypass surgery had gone well. At daybreak the phone rang - get here as quickly as you can.
She and her daughters rushed to Waikato Hospital, and waited outside the intensive care unit for four-and-a-half excruciating hours.
It was March 7, 2014. Lewis Baker, a 75-year-old retired teacher, had undergone surgery after suffering chest pains a few weeks earlier.
The operation was successful, but now he was crashing. Staff carrying bags of blood hurried past his anxious family. In the ICU, medics tried frantically to save Baker. A surgeon cut his chest open again, revealing a heart badly swollen because of a blood clot. They couldn't revive him. Finally, somebody read out the time: 11.13am.
In the waiting area, two doctors approached Elizabeth Baker, looking grim.
"I'll always remember them saying, 'He's gone. I'm sorry,'" she told the Herald recently. "That was it. 'He's gone. I'm sorry.'
"I shook hands with both of them, because I knew they'd tried their utmost."
However, the former nurse, who lives in Tauranga, became alarmed when she later examined her husband's medical file. On her reading of the records, a junior registrar on duty took much too long to raise the alarm after her husband's condition deteriorated.
In her view, her husband would still be alive had senior staff been alerted earlier. She hired a lawyer and asked the coroner to investigate.
In a finding made in January 2017, which has not been reported by the media until now, Chief Coroner Judge Deborah Marshall said it was impossible to know whether Baker could've been saved, but he had not been "given the benefit of specialist advice at a critical time".
Waikato DHB told Marshall it had conducted a serious incident review after the death and made changes to protect patients, including boosting the number of registrars. Those assurances were accepted and the chief coroner didn't recommend additional changes.
Elizabeth Baker wasn't satisfied: her family never received an apology from the DHB, she says, and she wasn't convinced it had fixed the problems she believes led to her husband's death. However, having exhausted the legal process, she gave up pursuing the complaint. Then last month she read an investigation in the Herald about historic problems in Waikato's cardiac surgery service.
The Herald obtained a damning report compiled in 2018 by a panel of Australian experts which, among other serious concerns, found that the ICU was "grossly understaffed" with senior specialists capable of handling cardiac surgery cases. This was, the report warned, an "immediate" and "critical" risk to patient safety.
As she read, Baker says she was struck that, four years after her husband's death, problems in his treatment were still present: staff who were apparently out of their depth, and poor teamwork and training. Despite their assurances to the coroner, Baker believes hospital leaders didn't learn from her husband's death.
"They had the opportunity and they blew it."
A life cut short
Elizabeth MacDonald and Lewis Baker met in their native England in 1960, when she was 19 and studying at London's West Middlesex Hospital, and he was training to be a teacher in nearby Twickenham.
They married after graduating and later applied to migrate to New Zealand on a whim after accompanying a friend to New Zealand House. After six weeks on the HMS Himalaya with two young children, they settled in Murupara - a contrast to London, but one they loved, given the bustle of the booming forestry town, reached then by an unsealed road and filled with other immigrants including from Britain, Scandinavia and Canada.
"I don't think I stopped laughing for four years," Baker recalls of the friendships made at that time.
They were married for 50 years and had six children. He was "a man of integrity and quiet conviction," one of his daughter's told the coroner. He headed the PE department at Auckland's Avondale College for 15 years. When the Bakers retired, they moved to Australia's Gold Coast ("Glitzy, cheap, vulgar and I loved it," said Baker) but the pull of children and grandchildren brought them back to New Zealand.
Eight months later, Lewis Baker - who was fit and had no known prior heart problems - was in an ambulance with chest pains. He was transferred to Waikato, where he had a quadruple bypass on March 6, 2014, after which he was moved to the ICU for monitoring overnight. His wife and daughters stayed at a nearby motel.
He felt nauseous during the night. After 1am his arterial blood pressure dropped. A senior nurse told the inquest she couldn't get instructions from a junior registrar, who was relatively new to the ICU. He denied being contacted but couldn't recall what he was doing.
After 4.30am the nurse became more worried about what she regarded as marked changes in Baker's condition. He was pale and sweating, and complaining of pain. The registrar ordered a red blood cell transfusion. More noradrenaline, a drug to raise blood pressure, was given.
About 5am, the nurse took her concerns to her superior. The associate charge nurse manager recalled asking the doctor what he thought was wrong, what they needed to do, and if they needed assistance. "Her evidence is that he did not reply to any of her questions," the coroner said.
The registrar's initial diagnosis was hypovolemia, a decrease of blood in the body. He ordered fluids be given. According to his evidence, Lewis responded well.
Around 5.30am the associate charge nurse manager used electrodes to pace Lewis' heart, because his need for noradrenaline was rising. She told the coroner she asked the registrar if he was going to call a senior doctor for help, but he asked her why he would want to do that. She felt "undermined and shut down".
The patient's condition worsened. He was confused and agitated. About 6.10am the registrar called a cardiothoracic registrar for help, but didn't express any urgency. Twenty minutes later, he rang another registrar, now asking for immediate assistance.
Baker tried to get out of bed and his surgeon was called to do the chest reopening. He reached the hospital within 10 minutes.
The surgeon told the inquest that, had he been present and seen the test results, he would have done the chest reopening by 5.40am. He testified that Baker would still be alive if he'd done the procedure at 6am, although he softened that position in cross-examination and said he couldn't be sure Baker would have lived because reopening his chest can trigger complications.
Marshall concluded the registrar acted to the best of his ability, but should have called for help soon after 5.30am.
In his evidence, the registrar said by 5.45am he was in a "diagnostic vortex". In hindsight, he agreed he should've called for help earlier. He didn't accept he had intentionally not communicated and talked of the need to sometimes shut out "noise" to concentrate.
"I accept my singular focus on Mr Baker meant I did not call for help immediately and if I could change one thing about that night it would be to call for [the ICU director] immediately," he said in his evidence.
After Baker's death, the doctor's decisions were monitored for a time. He no longer works at the hospital.
The coroner's inquest found systemic problems. There was no "access" nurse available - these are experienced nurses who can help maintain an overview of the situation in the ICU. And the unit's registrar roster at the time was "very arduous", which caused fatigue, the director of the intensive care department told the court.
The registrar hadn't been able to complete his orientation because of rostering. A serious incident review done by the DHB concluded "inexperience, coupled with no training in either chest reopening or teamwork in crisis resulted in a meaningful (and ultimately lethal) delay", the coronial findings noted.
Waikato DHB told the court changes had been made, including more training on chest re-openings, ensuring all registrars complete orientation, and hiring more staff to spread the burden of night shifts.
The chief coroner declined to recommend further changes. Waikato's lawyers had insisted none were needed because "staff are well aware that on-call consultants can and should be called out if there are any concerns about a patient", Marshall wrote. "In addition, the hospital does not consider there is any need to reassess the staffing levels at the ICU."
Independent report finds 'broken system'
In fact, Waikato's cardiac surgery service had a host of serious problems at around this time that went far beyond what the DHB acknowledged publicly.
According to the secret report obtained by the Herald, DHB data indicated there may have been a spike in cardiology deaths. Concerned, hospital leaders ordered an independent review of the service, the country's second-biggest. They brought in a team of Australian experts, which included highly experienced and respected surgeons and critical-care specialists and nurses.
In November 2018 the inquiry panel gave a harshly critical assessment, describing a "broken system" that had contributed to "concerning outcomes for patients". Bullying and oppressive behaviour were "prevalent at all levels of the organisation", the report found, with staff "struggling to survive in the current environment and [who] are calling out for resources, an effective leadership and interdepartmental collegiality."
The reviewers criticised the ICU where Baker died. "The panel feel that the intensive care unit staffing is a critical risk in the provision of sustainable and safe patient care. It was felt that a disinvestment in junior ICU staff and employment of more appropriately skilled, senior ICU staff should be considered."
Most intensivists didn't have the skills required to manage complex cardiac surgery patients, the inquiry concluded.
Its recommendations included ensuring "collegial professional communication and respect for each other's clinical strengths" in the ICU. The intensivist has the final say, the review noted, but "this will be in the setting of respectful communication and collaboration". Clear policies for when concerns about a patient must be escalated must be agreed to, the experts said.
The DHB should consider establishing an intensive care unit dedicated to cardiac surgery patients, the panel said. "On-calls in an ICU such as Waikato can be onerous . . . this needs to be appreciated by all, as must the fact that junior ICU staff are not necessarily familiar with all types of the ICU case mix."
As a result of this report, the DHB undertook a two-year overhaul of its cardiac surgery service aimed at improving its governance procedures, surgical facilities and teamwork among its staff. However, the DHB revealed this only in response to questions from the Herald after it obtained the full unredacted report.
Waikato insisted no patients were harmed as a "direct consequence" of the problems identified in the 2018 report, and criticised the panel for including "speculation" in their findings and "procedural deficiencies" in their review process.
It said that further analysis of the patient data that triggered the review found there had not been an increase in mortality. In 2020, it added, its cardiac surgery survival rate was in line with "clinical modelling" and similar to that of other hospitals in Australasia. There were "strong surgery success rates, with extremely low complications and faster recovery times".
Asked if the response to Lewis Baker's death was adequate, a Waikato DHB spokesperson said the coroner's investigation "noted that potential recommendations for additional orientation and training for junior staff had already been addressed by the DHB and therefore no further recommendations were made". The Health & Disability Commissioner had also declined to investigate further, the spokesperson noted.
On the independent review's recommendation to consider an ICU dedicated to cardiac surgery patients, the DHB said a "pod" of six beds for cardiac patients within the ICU operated prior to the case, and remains in service.
The Herald has filed further Official Information Act requests seeking more information about the cardiac surgery review, including analyses of patient mortality and survival rates.
Elizabeth Baker isn't convinced by Waikato DHB's responses.
After her husband's death, she spent five weeks confined to bed with pneumonia. The mental wounds have lasted far longer.
"To this day, it's nearly eight years later and I am absolutely consumed, consumed with grief," says Baker, now aged 81. "I'm hurt to the core."
Her relationship with him wasn't based just on love, she says, but "total and utter adoration". The loss is more painful because authorities didn't learn from what happened, she says, and that allowed problems to fester, putting others at risk.
"It was something for them to listen to and look at, and go through the whole set-up," she says. "It was a brilliant, missed opportunity."
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